Diocese of Ogdensburg

The Roman Catholic Church in Northern New York

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Minor's Information
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Mother/Legal Guardian Information
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Father/Legal Guardian Information
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Section A – Travel Arrangements
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Section B – Minor’s Health Information
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A photocopy of the front and back of your health insurance card must be provided. If you are unable to upload your health insurance card, please mail a copy to Diocesan Faith Formation Eastern Regional Center Attention: Andi Page 4917 S. Catherine Street Plattsburgh, NY 12901
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Healthcare Provider Information
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By eSigning my name above, I hereby affirm and certify that the information provided in Section B – Minor’s Health Information is complete and accurate to the best of my knowledge. My child/ward has my permission to participate in the Diocesan Lenten Retreat activities except as noted.
Section C - Self-Directed Medication
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By eSigning my name above, I certify the above-mentioned Minor is capable and competent to administer their prescribed medication and to self-carry their prescribed medication.
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By eSigning my name above, I certify that I have been instructed in and understand the purpose, time of day, dosage and frequency of my prescribed medication and consider myself capable and competent to administer and self-carry my prescribed medication.
Section D – Emergency Contact Information
If a parent/legal guardian cannot be reached in case of an emergency, please contact:
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By eSigning my name above, I hereby authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above-named Minor. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event, it becomes necessary for the staff of the Diocese of Ogdensburg Lenten Retreat in charge to obtain necessary care for my child/ward, neither he/she nor the Diocese of Ogdensburg assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstance.
Section E – General Rules
Boundaries- All participants must remain within the given boundaries and areas of the Lenten Retreat. No Alcohol, Illegal Drugs or Tobacco – These substances are prohibited during the Lenten Retreat. Behavior and Dress Code – All participants are expected to behave and dress in an appropriate manner throughout the Lenten Retreat. The following dress code must be followed throughout the Lenten Retreat: no clothing with advertisements for alcohol, drugs or tobacco. No inappropriate slogans or designs. Shirts must cover the midriff. Skirts, dresses or shorts must be no more than five inches above the knee. Respect the Staff – All staff will be given the Participant’s respect, courtesy and cooperation during the Lenten Retreat. Illness or Injury – Any illness or injury during the Lenten Retreat must be reported to a staff member immediately. Cell Phones – No cell phones will be permitted during the Lenten Retreat. Any emergencies should be reported to a staff member. Any serious infraction of the rules will result in a call to the Participant’s Parent/Legal Guardian and possible dismissal from the Lenten Retreat. The Parent/Legal Guardian will be responsible to pick the Participant up from the Lenten Retreat.
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By eSigning my name above, I certify that I have read and understand Section E – General Rules.
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By eSigning my name above, I certify that I have read and understand Section E – General Rules.
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By eSigning my name above, I hereby affirm and certify that the information provided in the Diocese of Ogdensburg Lenten Retreat registration form is complete and accurate to the best of my knowledge.
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